What is Quality Spiritual Care in Health Care and How Do You Measure It?
Purpose
This statement provides guidance to advocacy groups, professional health care associations, health care administrators, clinical teams, clients, family caregivers, researchers, government and other funders, faith communities, spiritual care professionals and other stakeholders internationally on the indicators of quality and experience of spiritual care in health care, the metrics that indicate quality care is present, and evidence- based tools that can measure and report that quality.
Reason for Action
The value of any health care service is increasingly determined and reimbursed by the quality of the health outcomes that are achieved relative to the costs of care rather than by the volume of services that are produced1. The COVID pandemic raised awareness of systemic racism and exposed the racial inequities in health care. The pandemic also highlighted the need for high quality spiritual care.2,3 Providing culturally responsive care includes assessment of spiritual needs which are often of great importance in diverse communities. Determining and improving the quality of care requires an acknowledged and robust set of quality indicators, the metrics which can identify and delineate quality, and tools which reliably measure those indicators While there is a fast- growing body of literature supporting quality spiritual care and wide-spread consensus that spiritual care is desired by patients and family caregivers, there is a paucity of valid and reliable measures for determining the quality of spiritual care with the exception of the Quality of Spiritual Care (QSC) scale4. The use of Patient Reported Outcome Measures in spiritual care is also increasing in prevalence and scope5 and can serve to humanize and balance out validated and well-recognized health and health services indices such as symptom severity and cure rates. The growing interest in spiritual care demands ways of capturing, aggregating, and exchanging data across a variety of care sites, using electronic health records and health information technology.
There is a continuing need to address these gaps by developing and updating indicators that demonstrate the impact of spiritual care on health and health outcomes. In response, this panel of international, multidisciplinary experts reviewed measures, instruments, and tools that have been either guideline-based, or have been empirically developed and tested. The statement seeks to provide guidance to providers of spiritual care, and those who advocate for that care, on the indicators of quality spiritual care, the metrics which measure those indicators and suggested tools which can reliably quantify those indicators. We see this document as a step in a continuing process of defining and promoting quality indicators in spiritual care.
Recommendations
Quality Indicator | Metric | Suggested Tools |
| 1. Structural Indicators | ||
1.A – Certified or credentialed spiritual care professional(s) are provided proportionate to the size and complexity of the unit served and officially recognized as integrated/embedded members of the clinical staff.6,7,8,9 | Institutional policy recognizes chaplains as official members of the clinical team. | Policy Review |
| 1.B – Dedicated inclusive sacred space is available for meditation, reflection and ritual.10,11 | Yes/No | |
| 1.C – Information is provided about the availability of spiritual care services.12 | Percentage of clients and family members surveyed who report they were informed that spiritual care was available | Client Satisfaction Survey |
1.D – Professional education and development programs in spiritual care are provided for all clinical disciplines to improve their provision of generalist spiritual care.13,14 | Percentage of clinical staff who report receiving spiritual care training appropriate to their scope of practice. | Lists of programs, number of attendees and feedback forms. |
1.E – Spiritual care quality measures are reported regularly as part of the organization’s overall quality program and are used to improve practice.15,16. | List of spiritual care quality measures reported in quality improvement dashboards. | Audit of organizational quality data and improvement initiatives. |
| 2. Process Indicators | ||
| 2.A – Specialist spiritual care is made available in a timely manner.6 | Percentage of staff who made referrals to spiritual care and report a timely response. | Survey of staff. Chaplaincy data reports |
| Quality Indicator | Metric | Suggested Tools |
| Percentage of referrals responded to within Chaplaincy Service guidelines. | ||
2.B – All clients are offered the opportunity to have a discussion of religious/spiritual concerns17,18 | Percentage of clients surveyed who say they were offered a discussion of religious/spiritual concerns | Client Survey |
2.C – An assessment of religious, spiritual, and existential concerns using a structured instrument is conducted and documented, and the information obtained from the assessment is integrated into the overall care plan.4,6 | Percentage of clients assessed using established tools such as FICA,19 Hope20 ,7X721, PC-7 22 , AIM23or Outcome Oriented24 models with a spiritual care plan as part of the overall plan of care. | Chart Review |
2.D – Spiritual, religious, and cultural practices are facilitated for clients, the people important to them and staff4 | Number of referrals for spiritual practices. Spiritual care practices documented in clients’ records Usage of sacred space. | Referral Logs including disposition of referrals and client satisfaction surveys. Chart audit |
| 2.E – Families are offered the opportunity to discuss spiritual issues during goals of care conferences25,26 | Percentage of care conference reports in which it is noted that families are given the opportunity to discuss spiritual issues or referrals are made to spiritual care. | Chart Audit |
2.F. Spiritual care is provided in a culturally and linguistically appropriate manner (e.g. client’s language and literacy level).4 Clients’ values and beliefs are integrated into plans of care. 27,28 | Percentage of clients surveyed who say that they were provided care in a culturally and linguistically appropriate manner. Percentage of documented plans of care that mention client beliefs and values. | Client Survey. Chart audit |
| Quality Indicator | Metric | Suggested Tools |
2.G. End of life and Bereavement Care is timely and provided as appropriate to the population served. 29,4,30 | Percentage of care plans for clients approaching end of life that include attention to end of life care and a plan for bereavement care after death. | Chart Audit. |
2. H. Spiritual care is offered to all staff formally (e.g. groups and scheduled meetings) and informally (e.g. unscheduled encounters).31,32,33 | Number of requests for spiritual care received and attendance at events open to staff such as worship, meditation, memorial services, support groups, and debriefings. | Referrals and activity logs. |
| 3. Outcomes | ||
| 3.A Client spiritual needs are met.34 | Percentage of clients surveyed reporting that spiritual needs were met. | · Spiritual Needs Assessment Inventory for Patients (SNAP)35 · Spiritual Needs Questionnaire (SpNQ)36 |
3.B – Spiritual care positively impacts client satisfaction37,38 | Client satisfaction is higher for those who receive spiritual care. | · HCAHPS #2139 · QSC2 |
| 3.C – Spiritual care reduces client spiritual distress 22,40,41 | Percentage of clients reporting reduced spiritual distress after spiritual care. | “Are you experiencing spiritual pain right now?” 42,43 Client Survey |
| 3.D – Spiritual care positively impacts clients’ sense of peace.44 | Percentage of clients surveyed reporting increased sense of peace after spiritual care. | · Facit-SP-Peace Subscale45 · “Are you at Peace?”46 · Client Survey · PROMs |
| · | ||
3.E – Spiritual care positively impacts meaning-making for clients and family members. 47,48 | Percentage of clients surveyed reporting increased ability to find measure of meaning after spiritual care. | · Facit-SP- Meaning subscale · RCOPE49 · Client Survey |
| Quality Indicator | Metric | Suggested Tools |
3.F – Spiritual care positively impacts spiritual well-being and overall quality of life.50,51, 32 | Percentage of clients surveyed reporting increased spiritual well-being after spiritual care. | · Facit-SP |
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The list of quality indicators was originally developed in 2016 by a distinguished, international panel of experts convened by HealthCare Chaplaincy Network. References were updated in 2019 and the full document was updated and reviewed by the panel below in 2021.
Timothy Daaleman, DO, MPH, professor of family medicine, University of North Carolina at Chapel Hill, N.C.
Betty Ferrell, Ph.D., M.A., F.A.A.N., F.P.C.N., director and professor, Division of Nursing Research and Education, Department of Population Sciences, City of Hope Comprehensive Cancer Center, Duarte, CA.
Charles W. Fluharty, Ph.D. Founder and president emeritus, Rural Policy Research Institute, Iowa City, Iowa
Rev. Eric J. Hall, M. Div., MA, president and CEO, HealthCare Chaplaincy Network, New York, NY
The Rev. George Handzo, BCC, CSSBB, director of health services research and quality, HealthCare Chaplaincy Network, New York, NY
Cheryl Holmes, OAM, CEO, Spiritual Health Association, Melbourne, Australia
Diane Meier, M.D., FACP, director, Center to Advance Palliative Care (CAPC), New York, NY
- Sean Morrison, M.D., director, Lilian and Benjamin Hertzberg Palliative Care Institute and the National Palliative Care Research Center at Mount Sinai, New York
Shane Sinclair, Ph.D., associate professor, Cancer Care Research Professorship, Director, Compassion Research Lab., Faculty of Nursing, University of Calgary, Alberta, Canada
The Rev. Sue Wintz, M.Div., BCC, director of professional and community education, HealthCare Chaplaincy Network, New York
